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The Journal of Thoracic and Cardiovascular Surgery, Vol 106, 850-858, Copyright © 1993 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
JA Hagen, JH Peters and TR DeMeester
The belief that transhiatal esophagogastrectomy results in the same
survival as a more extensive en bloc resection was tested in 69 patients
with carcinoma in the distal esophagus and gastric cardia. Preoperative and
intraoperative staging defined three distinct subgroups of patients. Those
with apparently limited disease and good general health (group I, n = 30)
underwent en bloc resection. Those with apparently limited disease but poor
physiologic reserve (group II, n = 16) underwent transhiatal resection, as
did those with evidence of more advanced disease (group III, n = 23).
Overall, survival was significantly better in the 30 patients who underwent
en bloc resection (41%) than in the 39 patients who underwent transhiatal
resections (14%; p < 0.001, log-rank). Clinical staging showed
apparently limited disease in 46 patients (groups I and II). These groups
differed only in the presence of poor physiologic reserve because the
percentages of patients with tumors limited to the esophageal wall (group I
13/30, group II 6/16) and four or fewer lymph node metastases (group I
21/30, group II 15/16) at the time of pathologic staging were not
significantly different. Survival after en bloc resection was, however,
significantly better (41% versus 21%; p < 0.05, log-rank). According to
the WNM system of pathologic staging, 19 patients had early lesions defined
as intramural lesions associated with four or fewer lymph node metastases,
26 had intermediate lesions defined as either transmural or associated with
more than four lymph node metastases, and 24 had late lesions defined as
both transmural and associated with fewer than four lymph node metastases.
Survival was significantly better in patients with early lesions after en
bloc resection compared with transhiatal resection (75% versus 20%, p <
0.01), survival was also significantly better in patients with advanced
lesions (27% versus 9%, p < 0.01). For intermediate lesions, the
survival was similar (14% versus 20%), although the median survival after
en bloc resection was longer (24 months versus 8 months).
ARTICLES
Superiority of extended en bloc esophagogastrectomy for carcinoma of the lower esophagus and cardia
University of Southern California School of Medicine, Department of Surgery, Los Angeles 90033-4612.
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